Dear Patient, Welcome to UNITY HEALTHCARE PHARMACY and to Our PRESCRIPTION PATHFINDER PROGRAM! We Are Excited to Provide All of Your Pharmacy Needs

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Dear Patient, Welcome to UNITY HEALTHCARE PHARMACY and to our PRESCRIPTION PATHFINDER PROGRAM! We are excited to provide all of your pharmacy needs. We care for patients located in the Washington D.C. area that have Hepatitis C and HIV. The staff at UNITY HEALTHCARE PHARMACY understands that your medical condition is complicated. You may need help with your medical provider and insurance company. We are dedicated to giving you the personal service you need to help you achieve the most benefit from your therapy. This help includes:

 Access to trained staff 24 hours a day, 7 days a week  Coordination of prior authorization with your insurance company  Help following medical advice for your medication  Free mailing of medication  Training, education, and counseling  Refill reminders  Enrollment in the Patient Management Program

Pharmacy Business Hours:[URAC CSCD 1(a-i, a-ii)]

Unity-Parkside Unity- Upper Cardozo Unity- East of the River Health 765 Kenilworth Terrace NE 3020 14th St. NW 4414 Benning Road NE, Suite 100 Washington, DC 20019 Washington, DC 20009 Washington, DC 20019 Phone: (844)370-6200 Phone: (844)370-6200 Phone: (844) 370-6200 Fax: (202) 558-0196 Fax: (202) 609-7112 Fax: (202) 396-2987 Hours: Hours: Hours: Monday-Friday: 8:30AM-5:30PM Monday-Friday: 8:30AM-5:30 PM Monday-Friday: 8:30AM-5:00PM Saturday-Sunday: Closed Saturday-Sunday: Closed Saturday-Sunday: Closed

We look forward to providing you with the best service possible. We thank you for choosing Unity Healthcare Pharmacy.

Sincerely,

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What to expect: We know that living with a chronic disease or serious illness can feel overwhelming. We are here for you. At UNITY HEALTHCARE PHARMACY, our staff is dedicated to working with you, your doctors and nurses, and family and friends to create a well working health care team. You are our primary purpose. You can expect:  Personalized Patient Care Our trained staff members will work with you to discuss your treatment plan. We will address any questions or concerns you may have.

 Working with your Doctor We will always keep the lines of communication open between you and your doctors and caregivers. We are here to make sure any problems you have with your treatment are addressed immediately with your physicians.

 Regular follow-up Getting your medications and medical supplies quickly is our number one goal. We will be in close contact with you during your treatment. We will be your healthcare advocate.

 Benefits Treatment can be costly. We will help you navigate the healthcare system so you know every option available to you. Our relationships with insurers will help provide you with information about your drug and medical benefits. Your quality of care is our highest mission.

 Free Delivery We offer fast delivery to where you want it. A staff member will contact you five to seven days prior to your refill due date to coordinate the medications you need. We update your medical and insurance records, and confirm a delivery date and address.

 24/7 Support Our Specialty Pharmacy staff is available 24 hours a day, 7 days a week for clinical questions. We are always here to answer any questions or address any concerns you have.

 Financial Obligation and Financial Assistance Before your care begins, a staff member will tell you what you will that is not covered by your insurance or other third-party sources. This may include but is not limited to: out-of-pocket costs such as deductibles, co- pays, co-insurance, annual, and lifetime co-insurance limits and changes that occur during your enrollment period.

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 Insurance claims [URAC CSCD 1 (c)] Staff will submit claims to your health insurance carrier on the date your prescription is filled. If the claim is rejected, a staff member will notify you so that we can work together to resolve the issue.  Co-payments [URAC CSCD 1 (b)] We are required to collect all co-payments prior to shipment of your medication. Co- payments can be paid by credit card or debit card over the phone.  Co-pay Assistance Referral Program We have access to financial assistance programs to help with co-payments to ensure no interruptions in your therapy. These programs include discount coupons from drug manufacturers, co-payment vouchers, and assistance from various disease management foundations and pharmaceutical companies.

 Patient Management Program [URAC PM 10 (b-i, b-ii, b-iii)]

As a patient of our Prescription Pathfinder Specialty Pharmacy Program, we will monitor your medications and progress through a disease specific Patient Management Program.

Benefits of using our Patient Management Program include help with managing side effects, increasing adherence with drug therapies and overall improvement of health when the patient is actively engaged and is compliant to therapy. Limitations of the Patient Management Program may include lack of patient self-reporting and patient participation. If you wish to opt out of the Patient Management Program, please call and speak to our pharmacy staff.

PATIENT BILL OF RIGHTS AND RESPONSIBILITIES

UNITY HEALTHCARE PHARMACY recognizes that patients have inherent rights. Patients who feel their rights have not been respected, or who have questions or concerns, should talk to the Director of Pharmacy. Patients and their families also have responsibilities while under the care of UNITY HEALTHCARE PHARMACY in order to facilitate the provision of safe, high-quality health care for themselves and others. The following patient rights and responsibilities shall be provided to, and expected from, patients or legally authorized individuals.

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PATIENT RIGHTS & RESPONSIBILITIES

To ensure the finest care possible, as a patient receiving our pharmacy services, you should understand your role, rights, and responsibilities involved in your plan of care.

Patient Rights [URAC CSCD 1 (e-i)]

 To select those who provide you with pharmacy services  To receive the appropriate or prescribed services in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference, physical or mental handicap  To be treated with friendliness, courtesy, and respect by each and every individual representing our pharmacy, who provided treatment or services for you and be free from neglect or abuse, be it physical or mental  To assist in the development and preparation of your plan of care that is designed to satisfy, as best as possible, your current needs  To be provided with adequate information from which you can give your informed consent for commencement of services, the continuation of services, the transfer of services to another health care provider, or the termination of services [URAC CSCD 1 (d-viii)]  To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, risk of treatment or care plans [URAC CSCD 1 (e-ii)]  To receive treatment and services within the scope of your plan of care, promptly and professionally, while being fully informed as to our pharmacy’s policies, procedures, and charges  To request and receive data regarding treatment, services, or costs thereof, privately and with confidentially  To be given information as it relates to the uses and disclosure of your plan of care  To have your plan of care remain private and confidential, except as required and permitted by law  To receive instructions on handling drug recall  To confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information; PHI will only be shared with the Patient Management Program in accordance with state and federal law [URAC PM 12 (b)]  To receive information on how to access support from consumer advocate groups [URAC CSCD 1 (a-iv)]  To receive pharmacy health and safety information to include consumers rights and responsibilities [URAC CSCD 1 (e-iv)]  To know about philosophy and characteristics of the patient management program [URAC PM 12 (a)]  To identify the program’s staff members, including the program and their job title, and to speak with a supervisor of the staff member’s supervisor if requested [URAC PM 12 (c)]  To speak to a healthcare professional [URAC PM 12 (d)]  To receive information about the patient management program [URAC PM 12 (e)]  To receive administrative information regarding changes in or termination of the patient management program [URAC PM 12 (f)]

 To decline participation, revoke consent, or dis-enroll at any point in time [URAC PM 12 (g)]  To be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care  To be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible  To receive information about the scope of services that the organization will provide and specific Revised March 2020 v1.9

limitations on those services  To participate in the development and periodic revision of the plan of care  To refuse care or treatment after the consequences of refusing care or treatment are fully presented  To be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable  To have one's property and person treated with respect, consideration, and recognition of client/patient dignity and individuality  To be able to identify visiting personnel members through proper identification  To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property  To voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal [URAC CSCD 1 (f)]  To have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated  To be advised on agency's policies and procedures regarding the disclosure of clinical records  To choose a health care provider, including choosing an attending physician, if applicable  To receive appropriate care without discrimination in accordance with physician orders, if applicable  To be informed of any financial benefits when referred to an organization  To be fully informed of one's responsibilities  To receive information about product selection, including suggestions of methods to obtain medications not available at the pharmacy where the product was ordered [URAC CSCD 1 (d-i)]  To receive information to assist in interactions with the organization [URAC CSCD 1 (a-iii)]  The right to receive information about an order delay, and assistance in obtaining the medication elsewhere, if necessary. [URAC CSCD 1 (d-iv)]

Patient Responsibilities

 To provide accurate and complete information regarding your past and present medical history  To agree to a schedule of services and report any cancellation of scheduled appointments and/or treatments  To participate in the development and updating of a plan of care  To communicate whether you clearly comprehend the course of treatment and plan of care  To comply with the plan of care and clinical instructions  To accept responsibility for your actions, if refusing treatment or not complying with, the prescribed treatment and services  To respect the rights of pharmacy personnel  To notify your Physician and the Pharmacy with any potential side effects and/or complications [URAC CSCD 1 (e-v)]  To notify UNITY HEALTHCARE PHARMACY via telephone when medication supply is running low so refill maybe shipped to you promptly  To submit any forms that are necessary to participate in the program to the extent required by law [URAC PM 12 (h)]  To give accurate clinical and contact information and to notify the patient management program of changes in this information [URAC PM 12 (i)]  To notify their treating provider of their participation in the patient management program, if applicable [URAC PM 12 (j)]

If you have questions, concerns or issues that require assistance, please call us. Complaints will be forwarded to management and you will receive a response within 5 business days.

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Additional Information  Medication Recalls [URAC CSCD 1 (e-iii)]

 If you have questions about a drug recall or believe you may have been affected by a drug recall please contact Unity Healthcare Pharmacy staff. Unity Healthcare Pharmacy staff will contact patients when necessary if they have been affected by a recall. Adverse Effects to Medication [URAC CSCD 1 (e-v)]  If you are experiencing adverse effects to the medication, please contact your physician or Unity Healthcare Pharmacy staff.

Drug Substitution Protocols [URAC CSCD 1 (d-vii) (e-vi)]  From time to time, it is necessary to substitute generic drugs for brand name drugs. This could occur due to your insurance company preferring the generic be dispensed or to reduce your copay. If a substitution needs to be made a member of the specialty pharmacy staff will contact you prior to shipping the medication to inform you of the substitution.

 Complaints [URAC CSCD 1 (f)]

 Please contact the pharmacy by phone, fax, writing, and/or via website if you have questions, concerns, or complaints that require assistance. Complaints will be forwarded to management and you will receive a response within 5 business days.

 Patients and caregivers have the right to voice complaints regarding Unity Healthcare Pharmacy. Complaints may be made by phone, fax, writing, and/or via website.

 District of Columbia Board of Pharmacy . Website: http://doh.dc.gov/service/pharmacy . Telephone: (202) 442-5955 . Anyone may file a complaint against a pharmacy, but complaints must be received in writing. A consumer may fill out the on line complaint form or call the phone number above to have one mailed to you.  ACHC Complaint Information . Website: http://achc.org/contact/complaint-policy-process . For further information, you may contact ACHC toll-free at (855) 937-2242 or 919-785- 1214 and request the Complaints Department.

 URAC Complaint Info . Website: https://www.urac.org/complaint/ . Email Address: [email protected] Revised March 2020 v1.9

 Proper Disposal of Unused Medications [URAC CSCD 1 (e-iv)]  For instructions on how to properly dispose of unused medications please contact Unity Healthcare Pharmacy for instructions or go to the below FDA websites for information and instructions  Do not flush unused medications or pour them down a sink or drain. http://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuri ngsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm

 Proper Disposal of Sharps [URAC CSCD 1 (e-iv)]  Place all needles, syringes, and other sharp objects into a sharps container. This will be provided by the Pharmacy if you are prescribed an injectable medication.

 Refills [URAC CSCD 1 (d-ii, iii)]  A pharmacy team member will contact you 5-7 days prior to your refill date. Refills may also be requested online or you may speak with pharmacy representative If needed, we will assist you with a process to refill a prescription, which would otherwise be limited by your prescription benefit plan.

 Prescription Transfers [URAC CSCD 1 (d-v-iii)]  If our pharmacy can no longer service your medication, a pharmacist will transfer your prescription to another pharmacy. We will inform you of this transfer of care.  If you feel that our pharmacy is unable to meet your needs, we can transfer your prescription to the appropriate pharmacy of your choice.  Prescription transfers may be requested online or you may speak with a pharmacy representative.

EMERGENCY & DISASTER PREPAREDNESS PLAN [URAC CSCD 1 (d-iv)]

Unity Healthcare Pharmacy has a comprehensive emergency preparedness plan in case a disaster occurs. Disasters may include fire to our facility, chemical spills in the community, snow storms, tornadoes, and community evacuations. Our primary goal is to continue to service your prescription care needs. When there is a threat of disaster or inclement weather in the local area, Unity Healthcare Pharmacy will contact you prior to any atrocities the city may encounter.

However if there is a threat of disaster or inclement of weather in an area you reside which is outside of the District of Columbia area it is your responsibility to contact the pharmacy prior to the occurrence (if permissible). This process will ensure you have enough medication to sustain you.

Unity Healthcare Pharmacy will utilize every resource available to continue to service you. However, there may be circumstances where Unity Healthcare cannot meet your needs due to the scope of the disaster. In that case, you must utilize the resources of your local rescue or medical facility. Please read the guide below to aide you in case of an emergency or disaster:

1. The pharmacy will call you 3-5 days before any inclement weather emergencies such as a snowstorm utilizing the weather updates as point of reference a. If you are not in the District of Columbia area and are aware you will be experiencing inclement weather you are responsible for calling the pharmacy 3-5 days before the occurrence. 2. The pharmacy will send your medication via courier or UPS next day delivery during any suspected Revised March 2020 v1.9

inclement weather emergencies. 3. If the pharmacy cannot get your medication to you before an inclement weather emergency occurrence the pharmacy will transfer your medication to a local specialty pharmacy so you do not go without medication. 4. If a local disaster occurs and the pharmacy cannot reach you or you cannot reach the pharmacy, please listen to your local news and rescue centers for advice on obtaining medication. Visit your local hospital immediately if you will miss a dose. 5. The pharmacy recommends all patients leave a secondary emergency phone number. If you have an emergency that is not environmental but personal and you need your medication, please contact the pharmacy at your convenience and we will aide you.

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HOME SAFETY INFORMATION

Here are some helpful guidelines to help you keep a careful eye on your home and maintain safe habits. The safe way is always the best way to do things. Shortcuts may hurt. Correct unsafe conditions before they cause an accident. Take responsibility. Keep your home safe. Keep emergency phone numbers handy.

Cleaning your hands

The most important step to prevent the spread of germs and infections is hand washing. Wash your hands often. Be sure to wash your hands each time you:

 Touch any blood or body fluids  Touch bedpans, dressings, or other soiled items  Use the bathroom or bedpan

If you are coughing, sneezing, or blowing your nose, clean your hands often. Before you eat, always clean your hands.

 How you should clean your hands with soap and water  Wet your hands and wrists with warm water  Using soap, work up a good lather, and rub hard for 15 seconds or longer  Rinse your hands well  Dry your hands well  Use a clean paper towel to turn off the water and throw the paper towel away

 How you should clean your hands with hand sanitizers (waterless hand cleaners)  For gel product use one application  For foam product use a golf-ball size amount  Apply product to the palm of your hand  Rub your hands together and cover all surfaces of your hands and fingers until they are dry

Medication

 If children are in the home, store medications and poisons in childproof containers and out of reach  All medication should be labeled clearly and left in original containers  Do not give or take medication that were prescribed for other people  When taking or giving medication, read the label and measure doses carefully and know the side effects of the medication you are taking  Before administering an injectable medication for yourself or others wash your hands thoroughly and prepare a clean area to give the injection.

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Mobility Items When using mobility items to get around such as; canes, walkers, wheelchairs or crutches you should use extra care to prevent slips and falls.

 Use extreme care to avoid using walkers, canes or crutches on slippery or wet surfaces  Always put the wheelchairs or seated walkers in the lock position when standing up or before sitting down  Wear shoes when using these items and try to avoid obstacles in your path as well as soft and uneven surfaces Slips and Falls Slips and falls are the most common and often the most serious accidents in the home. Here are some things you can do to prevent them in your home.

 Arrange furniture to avoid an obstacle course  Secure throw rugs or remove them all together  Install handrails on all stairs, showers, bathtubs and toilets  Keep stairs clear and well lit  Place rubber mats or grids in showers and bath tubs  Use bath benches or shower chairs if you have muscle weakness, shortness of breath or dizziness  Wipe up all spilled water, oil or grease immediately  Pick up and keep surprises out from under foot including electrical cords  Keep drawers and cabinets closed  Install good lighting to avoid searching in the dark Lifting If it is too big, too heavy or too awkward to move alone -GET HELP. Here are some things you can do to prevent low back pain or injury.

 Stand close to the load with your feet apart for good balance  Bend your knees and straddle the load  Keep your back as straight as possible while you lift and carry the load  Avoid twisting your body when carrying a load  Plan ahead - clear your way Electrical Accidents Watch for early warning signs; overheating, a burning smell, sparks. Unplug the appliance and get it checked right away. Here are some things you can do to prevent electrical accidents.

 Keep cords and electrical appliances away from water  Do not plug cords under rugs, through doorways or near heaters. Check cords for damage before use  Extension cords must have a big enough wire for larger appliances  If you have a broken plug outlet or wire, get it fixed right away  Use a ground on 3-wire plugs to prevent shock in case of electrical fault Revised March 2020 v1.9

 Do not overload outlets with too many plugs  Use three-prong adapters when necessary

Smell Gas?

 Open windows and doors  Shut off appliance involved (You may be able to refer to the front of your telephone book for instructions regarding turning off the gas to your home)  Don't use matches or turn on electrical switches  Don't use telephone - dialing may create electrical sparks  Don't light candles  Call gas company from a neighbor's home  If your gas company offers free annual inspections, take advantage of them Fire Pre-plan and practice your fire escape. Plan for at least two ways out of your home. If your fire exit is through a window, make sure it opens easily. If you are in an apartment, know where the exit stairs are located. Do not use the elevator in a fire emergency. You may notify the fire department ahead of time if you have a disability or special needs. Here are some steps to prevent fires:  Install smoke detectors as they are your best early warning, test frequently and change the battery every year  If there is oxygen in use, place a "No Smoking" sign in plain view of all persons entering the home  Throw away old newspapers, magazines, and boxes  Empty wastebaskets and trashcans regularly  Do not allow ashtrays or toss matches into wastebaskets unless you know they are out and have been wetted down first or dump into toilet.  Have your chimney and fireplace checked frequently  Look for and repair cracks and loose mortar  Keep paper, wood and rugs away from area where sparks could hit them  Be careful when using space heaters.  Follow instructions when using heating pad to avoid serious burns.  Check your furnace and pipes regularly  If nearby walls or ceilings feel hot, add insulation  Keep a fire extinguisher in your home and know how to use it

If you have a fire or suspect fire 1. Take immediate action per plan - Escape is your top priority 2. Get help on the way - with no delay - CALL 9-1-1 3. If your fire escape is cut off, close the door and seal the cracks to hold back smoke and signal help from the window

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Patient Support Groups, Education, and Training

 Support  Visit www.mayoclinic.org  Type in your disease state/condition into the search bar and select the disease state  On the left hand side, click “Coping and support” Educational Resources and Consumer Advocacy Support

 For evidence-based health information and content for common conditions and diagnoses, including community support resources, you can visit the following websites: http://www.mayoclinic.org/diseases-conditions https://www.cdc.gov/ https://wwwcf.nlm.nih.gov/hsrr_search/index.cfm https://www.ncbi.nlm.nih.gov/pubmed/clinical https://www.fda.gov/Drugs/default.htm

HIPAA Privacy Policy The Health Insurance Portability & Accountability Act NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. A federal law called the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) creates new rights for clients of health care organizations. One of those rights is to information regarding the provider’s privacy practice. Under federal regulations, we must provide you with a copy of this Notice of Privacy Practices and ask that you sign a document stating that we gave the notice to you. You may review the Notice of Privacy Practices immediately or at a later time. At some point, you should read it carefully because it explains: • Generally how we use health care information about you; • That we, like other health care providers, may use and disclose health information about you as part of your treatment, to arrange for payment for services provided, and for our internal operations. We are not required to have separate permission for these uses and disclosures; • Other circumstances where we may use or disclose information about your health where we are not required to get your permission first;

 The rights you have with respect to health information we have about you, namely:

 Your right to have a copy of this privacy notice;

 Your right to review and copy health information that we may have about you;

 Your right to an accounting for how we use and disclose your health information under certain limited circumstances; Revised March 2020 v1.9

 Your right to request restrictions on how we use your health care information;

 Your right to request an amendment to information in our records that you think is in error; and your right to file a complaint if you think your privacy rights have been violated.

At Unity Health Pharmacy, we take your confidentiality very seriously. We encourage you to read this Notice and keep a copy of it for your records. THE POLICIES IN THIS NOTICE BECOME EFFECTIVE ON September 23, 2013. Who will follow this notice?

Unity Health Care, including all corporate entities and locations, our employees, volunteers, and contractors will comply with the protection of your privacy as described in this notice.

Our Pledge:

We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services that you receive at Unity to ensure that we care providing quality care and to comply with legal requirements. This notice applies to all of your health information that we maintain, whether created by our staff or others, and tells you about the ways in which we may use or disclose your personal health information.

We are required by law to give you this Notice of our Privacy Practices, follow the terms of this notice, and to ensure that your health information is kept private.

How We May Use and Disclose Your Health Information:

Your Rights:

You have the right to:

 Get a copy of your paper or electronic medical record  Correct your paper or electronic medical record  Request confidential communication  Ask us to limit the information we share  Get a list of those with whom we’ve shared your information  Get a copy of this privacy notice  Choose someone to act for you  File a complaint if you believe your privacy rights have been violated

Your Choices:

You have some choices in the way that we use and share information as we:

 Tell family and friends about your condition  Provide disaster relief  Include you in a hospital directory  Provide mental health care  Market our services and sell your information

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 Raise funds

Our Uses and Disclosures

We may use and share your information as we:

 Treat you  Run our organization  Bill for your services  Help with public health and safety issues  Do research  Comply with the law  Respond to organ and tissue donation requests  Work with a medical examiner or funeral director  Address workers’ compensation, law enforcement, and other government requests  Respond to lawsuits and legal actions

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

 You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.  We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

 You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.  We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

 You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

 You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

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Get a list of those with whom we’ve shared information

 You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

 You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

 If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.  We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

 You can complain if you feel we have violated your rights by contacting us using the information on page 1.  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/www.hhs.gov/ocr/privacy/hipaa/complaints//complaints/.  We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

 Share information with your family, close friends, or others involved in your care  Share information in a disaster relief situation  Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

 Marketing purposes

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 Sale of your information  Most sharing of psychotherapy notes

In the case of fundraising:

 We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

 We can use your health information and share it with other professionals who are treating you.  Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

 We can use and share your health information to run our practice, improve your care, and contact you when necessary.  Example: We use health information about you to manage your treatment and services.

Bill for your services

 We can use and share your health information to bill and get payment from health plans or other entities.  Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

 We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: https://www.hhs.gov/hipaa/for-individuals/notice-privacy- practices/index.html

Help with public health and safety issues

 We can share health information about you for certain situations such as:

a. Preventing disease b. Helping with product recalls c. Reporting adverse reactions to medications d. Reporting suspected abuse, neglect, or domestic violence e. Preventing or reducing a serious threat to anyone’s health or safety

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Do research

 We can use or share your information for health research

Comply with the law

 We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law

Respond to organ and tissue donation requests

 We can share health information about you with organ procurement organizations

Work with a medical examiner or funeral director

 We can share health information with a coroner, medical examiner, or funeral director when an individual dies

Address workers’ compensation, law enforcement, and other government requests

 We can use or share health information about you:

a. For workers’ compensation claims b. For law enforcement purposes or with a law enforcement official c. With health oversight agencies for activities authorized by law d. For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

 We can share health information about you in response to a court or administrative order, or in response to a subpoena

Unity participates in the electronic exchange of health information through a network of local hospitals and clinics. Unity may use and disclose information about you with other participants of the electronic exchange for treatment, payment and health care operations, consistent with HIPAA requirements and Unity policies. If you have questions about the electronic exchange, please contact the Privacy Officer.

Patients registered with our Patient Portal are able to access certain portions of their medical record directly- speak with a Patient Registration Clerk at your medical home for additional information and to register.

The unauthorized disclosure of mental health information violates the provision of the District of Columbia Mental Health Information Act of 1978 (§§ 7-1201.01 to 7-1207.02). All patients have the right to inspect their mental health information. Disclosure of mental health information may be made pursuant to a valid authorization by the client or as provided in Titles III or IV of the Act. The act provides for civil damages and criminal penalties for violation.

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Our Responsibilities

 We are required by law to maintain the privacy and security of your protected health information.  We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.  We must follow the duties and privacy practices described in this notice and give you a copy of it.  We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html Changes to the Terms of this Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing, faxing or e-mailing us a written description of your complaint or by telling us about your complaint in person or over the telephone:

Privacy Officer Unity Health Care 1100 New Jersey Ave., SE, Suite 500 Washington, DC 20003 202-715-7900 [email protected]

Please describe what happened and give us the dates and names of anyone involved. Please also let us know how to contact you so that we can respond to your complaint. You will not be penalized for filing a complaint.

Other Users and Disclosures of your Protected Health Information

Other uses and disclosures not described above or covered by applicable law will be made only with your written authorization. You may revoke your authorization, in writing, at any time. You understand that we are unable to take back any uses and disclosures that we have already made with your authorization, and that we are required to retain our records of the care that we have provided to you.

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ACKNOWLEDGEMENT OF INFORMATIONAL WELCOME PACKET TO UNITY HEALTHCARE PHARMACY’S PRESCRIPTION PATHFINDER PROGRAM

Please confirm that you have received the Welcome Packet to UNITY HEALTHCARE PHARMACY’S PRESCRIPTION PATHFINDER PROGRAM, by signing and returning this form in the enclosed postage paid envelope. Completed forms may be mailed to or dropped off at:

Unity-Parkside Unity- Upper Cardozo Unity- East of the River Health 765 Kenilworth Terrace NE 3020 14th St. NW 4414 Benning Road NE, Suite 100 Washington, DC 20019 Washington, DC 20009 Washington, DC 20019 Phone: (844)370-6200 Phone: (844)370-6200 Phone: (844) 370-6200 Fax: (202) 558-0196 Fax: (202) 609-7112 Fax: (202) 396-2987 Hours: Hours: Hours: Monday-Friday: 8:30AM-5:30PM Monday-Friday: 8:30AM-5:30PM Monday-Friday: 8:30AM-5:00PM Saturday-Sunday: Closed Saturday-Sunday: Closed Saturday-Sunday: Closed

I confirm that I have received the Welcome Packet to UNITY HEALTHCARE PHARMACY’S PRESCRIPTION PATHFINDER PROGRAM, which includes Hours of Operation, Contact Information, Patient Bill of Rights and Responsibilities, Financial Obligation, Medication Recalls, Complaint Process and information on Privacy and Confidentiality policies.

Name (Please Print)

Signature

Billing Address

City, State, Zip

Phone #

Date

Thank you for choosing UNITY HEALTHCARE PHARMACY to service all of your pharmacy needs.

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